A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions

A 3-year-old child who has an atrial septal defect and a heart rate of 120/min

A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL

A 2-year-old child who has diarrhea and reports abdominal pain

Answer and Explanation

The Correct Answer is A

A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.

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Correct Answer is D

Explanation

A. Scant lochia rubra with a few small clots. Lochia rubra is expected in the early postpartum period, and small clots are normal unless excessive bleeding occurs.
B. Urine output 2,500 mL/day. Increased urine output is expected postpartum as the body eliminates excess fluid retained during pregnancy.
C. Bilateral ankle edema. Mild edema is common postpartum due to fluid shifts and typically resolves on its own.
D. 4+ deep-tendon reflexes. Hyperreflexia is a sign of central nervous system irritability and may indicate preeclampsia, which requires immediate evaluation.

A. Small clots with tissue in the urine B. Dark red urine C. Urinary output 25 mL/hr D. Pain of 8 on a scale of 0 to 10

Correct Answer is A

Explanation

A. Small clots with tissue in the urine. It is expected for a client 2 days post-TURP to have small clots and tissue debris in the urine as part of the healing process. Continuous bladder irrigation (CBI) often helps clear these.

B. Dark red urine. Bright red or dark red urine can indicate active bleeding, which is not expected 2 days post-op and requires immediate intervention.

C. Urinary output 25 mL/hr. This is too low (normal output should be at least 30 mL/hr) and could indicate catheter blockage, dehydration, or renal impairment, which is not expected.

D. Pain of 8 on a scale of 0 to 10. Mild discomfort is expected, but severe pain (8/10) is abnormal and could indicate bladder spasms, catheter blockage, or another complication requiring intervention.

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A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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